Member Forms

Claim Forms

Medical 
Mail this form to the address listed on the back of your member identification (ID) card.

Dental
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Vision
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Prescription Drug Claim form for Major Medical Benefits
For members with one deductible for both covered medical and prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Prescription Drug Claim form for Drug Card Benefits 
For members with separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Prescription Drug Claim form for Drug Card Benefits (on exchange)
For members who bought a plan on the federal exchange and have separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Over the Counter (OTC) COVID-19 Test Reimbursement Claim Form (log in to My Health Plan)
On Jan. 10, 2022, health insurance plans, like Medical Mutual, received additional guidance from the federal government regarding making FDA-approved/authorized OTC COVID-19 tests available to our members at no cost to them starting Jan. 15, 2022. The guidance calls for coverage of 8 tests every 30 days per member. For more information on how you can request reimbursement for any tests you purchased on or after Jan. 15, log in to My Health Plan.

FlexSave Health Care and Dependent Care
Please Note: Your plan must be administered by Medical Mutual Services to use this form. 

FlexSave Parking and Transportation 
Please Note: Your plan must be administered by Medical Mutual Services to use this form. 

Miscellaneous Forms

Adult Dependent Form
Mail this form to: Medical Mutual, P.O. Box 943, Toledo, OH 43656-0001

Disability Verification
Mail this form to: Medical Mutual, 2060 East 9th Street, Cleveland, OH 44115-1355

FlexSave Direct Deposit Form 
Please Note: Your plan must be administered by Medical Mutual Services to use this form.

Prescription Drug Mail Order Form
This form is for members with prescription drug benefits through Express Scripts.

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